ATI RN
ATI Nur258 Med Surg 2 Final Exam Questions
Extract:
Question 1 of 5
A client arrives in the emergency department with an ischemic stroke. What is the priority for the nurse to assess in relation to the administration of tissue plasminogen activator (t-PA) as treatment?
Correct Answer: A
Rationale: Current anticoagulant use is crucial to assess before administering t-PA because combining t-PA with anticoagulants can significantly increase the risk of bleeding complications. It is essential to ensure that the client is not on medications that could interact adversely with t-PA.
Question 2 of 5
A nurse is teaching a female client with systemic lupus erythematosus (SLE) about exacerbating factors for their disease. Which statement about exacerbating factors by the client requires further teaching?
Correct Answer: A
Rationale: The statement about keeping the temperature cold to avoid becoming overheated requires further teaching. While avoiding excessive heat is important, maintaining an overly cold environment can also trigger symptoms, such as Raynaud's phenomenon, which is common in SLE patients. Proper temperature regulation, rather than extremes, is essential.
Question 3 of 5
A nurse is caring for a client who has syndrome of inappropriate antidiuretic hormone (SIADH) and a sodium level of 123 mEq/L (nl. 135-145 mEq/L). Which of the following prescriptions should the nurse anticipate?
Correct Answer: C
Rationale: Restricting fluid intake is a key management strategy for SIADH to address the fluid overload and help correct the low sodium levels. This action directly targets the root cause of the hyponatremia by reducing fluid intake.
Question 4 of 5
The nurse is caring for a client who is having chest pain. The healthcare provider prescribes an infusion of nitroglycerin. The initial dose is 12 mcg/min. The nitroglycerin is dispensed at a concentration of 100 mg/ 250 mL. How many mL/hr will the nurse set the infusion pump? (Round rate to the nearest tenth. Only enter numbers and decimals. Do not enter any letters in your answer.)
Correct Answer: 1.8
Rationale: Infusion rate = 0.72 mg/hr / 0.4 mg/mL = 1.8 mL/hr
Question 5 of 5
A nurse is caring for a client who experienced a right-hemispheric stroke and has extreme muscle weakness on the affected side. Which nursing intervention is most appropriate for this client?
Correct Answer: A
Rationale: A client with extreme muscle weakness on the affected side should use a cane or other assistive devices to aid in mobility and ensure safety. This intervention helps the client maintain stability and prevent falls.